Different physical factor therapies for knee osteoarthritis: a network meta-analysis of efficacy and safety

doi:10.12307/2026.868

Abstract

Abstract: OBJECTIVE: The therapeutic modalities of physical factor interventions for knee osteoarthritis have been increasingly diversified; however, comprehensive comparative evaluations of their efficacy remain limited. This study aims to compare the efficacy and safety of various physical factor therapies for knee osteoarthritis through a network meta-analysis.
METHODS: Randomized controlled trials on physical factor therapy for knee osteoarthritis were retrieved from PubMed, Web of Science, Cochrane Library, EMbase, CNKI, VIP, WanFang, and SinoMed databases from inception to July 25, 2025. Eligible studies were screened, and data were extracted. The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool. Statistical analyses were performed with Stata 16.0 and RevMan 5.4.1.
RESULTS: (1) A total of 65 randomized controlled trials involving 3 418 patients were included, with 1 726 in the intervention group and 1 692 in the control group, covering 7 types of physical factor-based rehabilitation regimens. (2) For overall clinical response rate, the top three interventions ranked by the surface under the cumulative ranking curve were pulsed electromagnetic field therapy > ultrasound therapy > transcutaneous electrical stimulation, each combined with conventional rehabilitation. For reduction in knee pain assessed by the visual analogue scale, the top three interventions ranked by the surface under the cumulative ranking curve were transcutaneous electrical stimulation > extracorporeal shock wave therapy > ultrasound, each combined with conventional rehabilitation. For improvement in total Western Ontario and McMaster Universities Arthritis Index scores, the top three interventions ranked by the surface under the cumulative ranking curve were ultrasound > pulsed electromagnetic field therapy > ultrasound plus transcutaneous electrical stimulation, each combined with conventional rehabilitation. For reduction in Western Ontario and McMaster Universities Arthritis Index stiffness subscale scores, the top three interventions ranked by the surface under the cumulative ranking curve were transcutaneous electrical stimulation > ultrasound > ultrasound plus transcutaneous electrical stimulation, each combined with conventional rehabilitation. For improvement in 36-Item Short Form Survey quality-of-life scores, the top three interventions ranked by the surface under the cumulative ranking curve were pulsed electromagnetic field therapy > extracorporeal shock wave therapy > ultrasound, each combined with conventional rehabilitation. For improvement in Lysholm knee scores, the top three interventions ranked by the surface under the cumulative ranking curve were ultrasound > ultrasound plus transcutaneous electrical stimulation > extracorporeal shock wave therapy, each combined with conventional rehabilitation. No serious adverse events were reported across the included studies; most trials only documented mild skin irritation or allergic reactions.
CONCLUSION: Based on the surface under the cumulative ranking curve and the results of the network meta-analysis, transcutaneous electrical nerve stimulation combined with conventional rehabilitation therapy demonstrated a relatively higher probability of benefit in improving visual analogue scale scores and Western Ontario and McMaster Universities Arthritis Index stiffness scores in patients with knee osteoarthritis; ultrasound therapy combined with conventional rehabilitation therapy showed comparatively better performance in improving Lysholm knee scores and total Western Ontario and McMaster Universities Arthritis Index scores; pulsed electromagnetic field therapy combined with conventional rehabilitation therapy exhibited a potential advantage in enhancing overall quality of life in patients with knee osteoarthritis. Each physical factor possesses its unique advantages; however, given the limitations in the quality and quantity of the included studies, these findings require further verification through high-quality, multicenter, large-sample randomized controlled trials.

Key words: knee osteoarthritis, physical factor therapy, network meta-analysis, clinical efficacy, non-surgical treatment, rehabilitation therapy, systematic review

CLC Number:

Wu Ruiqi, Dong Panfeng, Zhang Hongrui, Lyu Yongbin, Peng Qinglin, Zhuo Yinghong, Chen Yueping . Different physical factor therapies for knee osteoarthritis: a network meta-analysis of efficacy and safety[J]. Chinese Journal of Tissue Engineering Research, 2026, 30(34): 9056-9066.

Figures/Tables 7

2.1 文献检索结果初步搜索获得1 832篇文献，通过EndNote X9自动结合手动剔除重复文献后剩余1 123篇，阅读标题和摘要后排除一些不相关且明显不符合纳入要求的文章，如动物细胞实验、手术相关研究、病例报告和综述等，下载了175篇文献以供进一步筛选。通过阅读全文，排除不符合纳入标准的文献，最终纳入65个随机对照试验。文献筛选流程见图3。 2.2 纳入文献的基本特征共纳入3 418例患者，均符合膝骨关节炎的临床诊断，其中治疗组1 726例、对照组1 692例，入选患者年龄40-75岁，其中55-70岁最常见。使用常规康复治疗作为对照组，包括常规的关节活动度训练、肌力训练、日常功能训练及一般护理指导等，试验组为常规康复治疗联合物理因子治疗，涉及超声波、脉冲电磁场、低能量激光、体外冲击波、经皮电刺激、全身振动和肌内效贴7种物理因子治疗，治疗持续时间为4-12周。结局指标方面，报道治疗总有效率的共有33项研究、膝关节目测类比评分的共有57项研究、WOMAC总评分的共有35项研究、WOMAC关节僵硬评分的共有29项研究，SF-36量表的24项研究、Lysholm膝关节评分的共有39项研究。纳入文献的基本特征，见表1。 2.3 纳入文献的质量评价纳入65篇文献均为随机对照试验[21-85]。随机顺序产生方面，29项为随机数字表法[22-23，28-30，32，35，39-41，45，48，57-59，63，65-67，69，71，74-77，79-80，83-84]，2项采用抽签随机法[51，54]，1项采用分层区组随机[69]，以上研究均判为“低风险”，1项根据治疗方案的不同进行分组[36]，2项按照患者采用就诊先后顺序[24，70]，均判为“高风险”，其余研究未报告具体随机方法判为“风险未知”。分配隐藏方面，7项研究采用信封法进行分配隐藏[26，59，29，67，69-70，83]，判为“低风险”，其余研究均未提及分配隐藏方案，评为“风险未知”。盲法方面，13项研究采用双盲[27，29，32，39，42，52，59，65，67，69，72-73，83]，均判为“低风险”，其余研究均未提及盲法判为“风险未知”。纳入研究数据完整，结局评价可靠，评为“低风险”。在选择性报告方面，均未在中国临床试验注册中心上搜索到研究计划书均评为“风险未知”。在其他来源偏倚风险方面，所有研究对资助来源等方面未报告均评为“风险未知”。采用RevMan 5.3软件绘制纳入研究的偏倚风险图，见图4。 2.4 治疗总有效率分析结果 2.4.1 证据网络 33项随机对照试验报道了治疗总有效率[23，26，31，39-40，47-49，51-56，58-70，73-75，80-82]，共涉及8种干预措施：超声波+常规康复、脉冲电磁场+常规康复、低能量激光+常规康复、体外冲击波+常规康复、经皮电刺激+常规康复、全身振动+常规康复、肌内效贴+常规康复和单纯常规康复治疗，总样本量2 689例。网络图中，各圆点分别表示不同的干预措施，圆点大小代表此干预措施的样本量，圆点之间连线粗细代表各干预措施的研究数量，直线表示2种干预措施间存在的直接或间接比较，不同干预措施间均存在直接或间接比较的证据，具备进行网状Meta分析的基本条件。治疗有效率的证据网络总体以常规康复治疗为中心，干预措施间无闭合环产生，无需进行不一致性检验，见图5A。 2.4.2 网状Meta分析与SUCRA排序对8种干预措施进行两两比较，共产生28项两两比较。网状Meta分析显示，肌内效贴+常规康复(OR=1.17，95%CI[1.07，1.29])、经皮电刺激+常规康复(OR=1.18，95%CI[1.12，1.26])、体外冲击波+常规康复(OR=1.17，95%CI[1.12，1.22])、脉冲电磁场+常规康复(OR=1.28，95%CI [1.03，1.57])、超声波+常规康复治疗(OR=1.24，95%CI[1.11，1.39])治疗在提高治疗总有效率均优于单纯常规康复治疗(P < 0.05)，其余干预措施间治疗总有效率相比较差异无显著性意义 (P > 0.05)，见图6A。在报告治疗总有效率的研究中，治疗总有效率的SUCRA值由高到低排序为：脉冲电磁场+常规康复(77.5%) >超声波+常规康复(76.8%) >经皮电刺激+常规康复(56.5%) >肌内效贴+常规康复(51.4%) >低能量激光+常规康复(50.0%) >体外冲击波+常规康复(47.4%) >全身振动+常规康复(38.7%) >常规康复(2.6%)，见图7A。"

2.5 膝关节目测类比评分分析结果 2.5.1 证据网络 57项随机对照试验报道了膝关节目测类比评分[22-28，30-33，35，37-45，47-60，62-80，83-85]，共涉及8种干预措施，总样本量4 044例，证据网络总体以常规康复治疗为中心，干预措施间无闭合环产生，故无需进行不一致性检验，见图5B。 2.5.2 网状Meta分析与SUCRA排序对8种干预措施进行两两比较，共产生28项两两比较。网状Meta分析显示，经皮电刺激+常规康复(SMD=-1.55，95%CI[-2.38，-0.73])、体外冲击波+常规康复(SMD=-1.27，95%CI[-1.88，-0.66])、超声波+常规康复(SMD=-1.15，95%CI [-1.89，-0.41])治疗在改善膝关节目测类比评分方面优于常规康复治疗(P < 0.05)，其余干预措施间相膝关节目测类比评分比较差异无显著性意义(P > 0.05)，见图6B。在报告膝关节目测类比评分的研究中，膝关节目测类比评分的SUCRA值概率排序为：经皮电刺激+常规康复(85.6%) >体外冲击波+常规康复(72.9%) >超声波+常规康复(65.8%) >肌内效贴+常规康复(57.1%) >脉冲电磁场+常规康复(53.0%) >低能量激光+常规康复(34.1%) >全身振动+常规康复(25.4%) >常规康复(6.1%)，见图7B。 2.6 WOMAC总评分分析结果 2.6.1 证据网络 35项随机对照试验报道了WOMAC总评分[21-22，24，28-29，32-35，38，40，46，48-50，52-54，57-58，60，63，65，67，69，72，74-75，77-80，83-85]，共涉及9种干预措施，总样本量2 379例，证据网络总体以常规康复治疗为中心，干预措施间产生闭合环，见图5C。为了确保分析结果的稳健性，需运用节点分裂法进行局部的一致性检验，检验结果显示P > 0.05，是说明研究间具有一致性，故在一致性模型下进行网状Meta分析。对闭环进行一致性检验，结果显示闭环IF=1.98、95%CI[0.73，3.42]，提示一致性良好。 2.6.2 网状Meta分析与SUCRA排序对9种干预措施进行两两比较，共产生36项两两比较。网状Meta分析显示，与常规康复治疗相比，肌内效贴+常规康复(SMD=-0.70，95%CI[-1.25，-0.15])、经皮电刺激+常规康复(SMD=-1.03，95%CI[-1.44，-0.62])、体外冲击波+常规康复(SMD=-1.06，95%CI[-1.99，-0.12])、低能量激光+常规康复(SMD=-1.18，95%CI[-1.83，-0.52])、脉冲电磁场+常规康复(SMD=-1.24，95%CI[-1.81，-0.67])治疗在减少WOMAC总评分方面的效果更佳(P < 0.05)，其余干预措施间WOMAC总评分相比较差异无显著性意义(P > 0.05)，见图6C。在报告WOMAC总评分的研究中，WOMAC总评分的SUCRA值由高到低排序为：超声波+常规康复(77.6%) >脉冲电磁场+常规康复(72.9%) >超声波+经皮电刺激+常规康复治疗(66.0%) >低能量激光+常规康复(63.8%) >体外冲击波+常规康复(63.5%) >全身振动+常规康复(40.7%) >肌内效贴+常规康复(31.3%) >经皮电刺激+常规康复(29.7%) >常规康复(4.6%)，见图7C。 2.7 WOMAC关节僵硬评分分析结果 2.7.1 证据网络 27项随机对照试验报道了WOMAC关节僵硬评分[21-22，24，28-31，33-34，37-38，41-46，49-50，52，55，57，72，76，79，82-83]，共涉及9种干预措施，总样本量2 000例，证据网络总体以常规康复治疗为中心，干预措施间无闭合环产生，故无需进行不一致性检验，见图5D。 2.7.2 网状Meta分析与SUCRA排序对9种干预措施进行两两比较，共产生36项两两比较。网状Meta分析显示，与常规康复治疗相比，超声波+经皮电刺激+常规康复(SMD=-1.19，95%CI[-2.10，-0.28])、经皮电刺激+常规康复(SMD=-1.52，95%CI[-2.18，-0.87])、体外冲击波+常规康复(SMD=-0.73，95%CI[-1.12，-0.34])、低能量激光+常规康复(SMD=-0.51，95%CI[-0.92，-0.11])、超声波+常规康复(SMD=-1.26，95%CI[-1.63，-0.89])在减少WOMAC关节僵硬评分方面的效果更佳。此外，经皮电刺激+常规康复治疗在减少WOMAC关节僵硬评分方面优于全身振动+常规康复(SMD=-1.10，95%CI[-1.99，-0.22])，超声波+常规康复治疗在减少WOMAC关节僵硬评分方面优于全身振动+常规康复(SMD=-0.83，95%CI[-1.54，-0.13])、低能量激光+常规康复(SMD=-0.75，95%CI[-1.29，-0.20])、脉冲电磁场+常规康复(SMD=-0.83，95%CI[-1.42，-0.24])治疗，差异有显著性意义(P < 0.05)，其余干预措施间WOMAC关节僵硬评分比较差异无显著性意义(P > 0.05)，见图6D。在报告WOMAC关节僵硬评分的研究中，WOMAC关节僵硬评分的SUCRA值由高到低排序为：经皮电刺激+常规康复(92.8%) >超声波+常规康复(83.9%) >超声波+经皮电刺激+常规康复(75.9%) >体外冲击波治疗+常规康复治疗(53.1%) >肌内效贴+常规康复(44.0%) >低能量激光+常规康复(37.0%) >全身振动+常规康复(30.9%) >脉冲电磁场+常规康复(30.1%) >常规康复(3.0%)，见图7D。 2.8 SF-36量表分析结果 2.8.1 证据网络 25项随机对照试验报道了SF-36量表[25-26，28-30，32-33，36，39，41，46，51，56，60，65-66，68，71，76-77，79，81，83-85]，共涉及8种干预措施，总样本量1 727例，证据网络总体以常规康复治疗为中心，干预措施间无闭合环产生，故无需进行不一致性检验，见图5E。 2.8.2 网状Meta分析与SUCRA排序对8种干预措施进行两两比较，共产生28项两两比较。网状Meta分析显示，肌内效贴+常规康复(SMD=0.63，95%CI[0.05，1.21])、全身振动+常规康复(SMD=0.93，95%CI[0.22，1.64])、体外冲击波+常规康复(SMD=0.97，95%CI[0.37，1.56])、脉冲电磁场+常规康复(SMD= 0.98，95%CI[0.35，1.60])、超声波+常规康复(SMD=0.93，95%CI[0.51，1.35])治疗在改善SF-36量表方面优于常规康复治疗(P < 0.05)，其余干预措施间SF-36量表相比较差异无显著性意义(P > 0.05)，见图6E。在报告SF-36量表的研究中，SF-36量表的SUCRA值由高到低排序为：脉冲电磁场+常规康复(72.8%) >体外冲击波+常规康复(72.2%) >超声波治疗+常规康复(70.8%) >全身振动+常规康复(68.4%) >肌内效贴+常规康复(45.4%) >经皮电刺激+常规康复(35.9%) >低能量激光+常规康复(29.8%) >常规康复(4.7%)，见图7E。 2.9 Lysholm膝关节评分分析结果 2.9.1 证据网络 38项随机对照试验报道了Lysholm膝关节评分[21，23-24，26，30，33-34，38-46，48-52，55，57-60，62-63，66，69-71，73，76，78-79，81，84]，共涉及9种干预措施，总样本量2 783例，证据网络总体以常规康复治疗为中心，干预措施间无闭合环产生，故无需进行不一致性检验，见图5F。2.9.2 网状Meta分析与SUCRA排序对9种干预措施进行两两比较，共产生36项两两比较。网状Meta分析显示，超声波+经皮电刺激+常规康复(SMD=1.80，95%CI[0.36，3.23])、经皮电刺激+常规康复(SMD=0.88，95%CI[0.29，1.46])、体外冲击波+常规康复(SMD=1.25，95%CI[0.86，1.65])、低能量激光+常规康复(SMD=0.68，95%CI[0.16，1.20])、超声波+常规康复(SMD=1.58，95%CI[0.91，2.25])治疗在改善Lysholm膝关节评分方面优于常规康复治疗(P < 0.05)；此外，体外冲击波+常规康复治疗在改善Lysholm膝关节评分方面优于脉冲电磁场+常规康复治疗(SMD=0.87，95%CI[0.16，1.58])，超声波+常规康复治疗在改善Lysholm膝关节评分方面优于脉冲电磁场+常规康复(SMD=1.20，95%CI[0.30，2.09])、低能量激光+常规康复治疗(SMD=0.90，95%CI[0.05，1.75])，差异有显著性意义(P < 0.05)，其余干预措施间"

Lysholm膝关节评分比较差异无显著性意义(P > 0.05)，见图6F。在报告Lysholm膝关节评分的研究中，Lysholm膝关节评分的SUCRA值由高到低排序为：超声波+常规康复(86.6%) >超声波+经皮电刺激+常规康复(86.5%) >体外冲击波+常规康复(74.1%) >经皮电刺激+常规康复(51.5%) >肌内效贴+常规康复(48.0%) >全身振动+常规康复(39.7%) >低能量激光+常规康复(38.9%) >脉冲电磁场+常规康复(22.3%) >常规康复(4.5%)，见图7F。 2.10 不良反应发生率 46项随机对照试验报道了不良反应发生率[21，23-25，27-30，32，34-36，39，41-43，45-47，49-50，53，55-57，59-61，63-67，70-73，75，77-82，84-85]，其中，32篇报告治疗期间均未发生与干预措施等相关的不良反应，14篇对不良反应发生情况进行了描述，共涉及8种干预措施，共有65例患者出现不良反应，主要包括皮肤刺激、过敏反应、肌肉或关节的酸痛感和治疗部位稍肿胀等表现，由于每个研究间不良反应不同，因此只作描述性统计，见表2。 2.11 文献发表偏倚此次研究对各结局指标进行发表偏倚分析，绘制“比较-矫正”漏斗图，进行偏倚分析，漏斗图中的圆点表示不同干预措施之间的一对一比较，点的颜色代表不同的干预措施或对照组类别，每种颜色点的数量代表报告比较的研究数量。如果不存在小样本量或发表偏差的影响，漏斗图中的点对称且均匀分布在垂直线的两侧(X=0)。检验结果显示，治疗总有效率、WOMAC总评分、WOMAC关节僵硬评分、SF-36量表和Lysholm膝关节评分结局指标的纳入研究总体对称分布于倒漏斗图的中上部，围绕中线左右两侧，提示发表偏倚的可能性较小；膝关节目测类比评分结局指标的漏斗图左右对称性欠佳，并且部分圆点散落在95%CI区域外，提示纳入文献可能存在一定的发表偏倚或是小样本效应，见图8。进一步进行对所有结局指标进行敏感性分析Egger检验，结果显示治疗总有效率的P=0.532、膝关节目测类比评分的 P=0.780、WOMAC总评分的P=0.322、WOMAC关节僵硬评分的P=0.725、SF-36量表的P=0.617、Lysholm膝关节评分的P=0.403，提示所纳入的研究不存在小样本研究效应且具有一定的稳健性。"

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